CEO of JPMorgan has Throat Cancer

Image from Wikipedia by Steve Jurvetson

The CEO and President of JPMorgan, Jamie Dimon, announced that he has throat cancer and is currently undergoing treatment at Memorial Sloan Kettering Cancer Center in Manhattan for the next eight weeks. According to a letter he sent to shareholders on July 1, 2014:

"I wanted to let you know that I have just been diagnosed with throat cancer. The good news is that the prognosis from my doctors is excellent, the cancer was caught quickly, and my condition is curable. Following thorough tests that included a CAT scan, PET scan and a biopsy, the cancer is confined to the original site and the adjacent lymph nodes on the right side of my neck. Importantly, there is no evidence of cancer elsewhere in my body." [link]

Based on this information, he has a Stage 3 or 4 (out of possible 4) throat cancer. Stage 1 is the early and best stage to have. It is less clear exactly where the throat cancer is whether it be tonsil, tongue, oropharynx, or some other location. Based on probabilities, he most likely has squamous cell carcinoma which is the most common type of cancer of the head and neck including the throat.

Although he states the prognosis is good, it is not as good compared to patients where no neck mass is present (Stage 1 or 2) where chemotherapy may not even be necessary.

He also mentions the word "curable" which I am leary of when he has just started treatment. Even if no cancer is detectable at the end of treatment, throat cancer, especially stage 3 or 4, has the potential to come back.

Recall the case of actor Larry Hagman of Dallas fame... He had throat cancer and was declared "cured" 8/29/12. Than on 11/24/13, he died of cancer recurrence and complications.

The risk of cancer recurrence is highest within the first 2-3 years after treatment completion, and markedly decreases after 5 years.

Typically if cancer has not come back after 5 years, the word "cure" may than be used, but even than, such patients are seen yearly for the rest of their life for cancer monitoring.

Because the risk of cancer recurrence is so high in the first few years after treatment completion, patients are seen frequently for the first 2-3 years after treatment.

Every 2 months for the first year. Every 3-4 months in the 2nd year. Every 4 months in the 3rd year. Every 6 months in the 4th year. Yearly starting at 5 years after treatment.

This type of follow-up applies to all head and neck cancer.

Source:
JPMorgan CEO Jamie Dimon has cancer. USA Today 7/2/14

JPMorgan CEO Jamie Dimon's letter to shareholders. USA Today 7/1/14

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Cricoid Pressure May Minimize Symptoms of Reflux (LPR)

Specifically throat symptoms attributable to reflux such as globus, throat-clearing, phlegmy throat, chronic cough, etc. However, cricoid pressure may not be realistic nor practical even if it does help.

In one of the more unusual studies I have seen, researchers deliberately infused 60 cc of hydrochloric acid into the esophagus of 14 patients who suffered from LPR as well as 12 healthy controls. 9 patients exhibited confirmed LPR (laryngopharyngeal reflux) events, but none in the control group. With moderate sustained cricoid pressure (20-30 mmHg), only one patient had a confirmed LPR event.

Theoretically, why would cricoid pressure work?

The cricoid cartilage is located immediately below the voice box. It is a circular cartilage that is right at the level where the throat connects to the esophagus. By putting pressure on the cricoid cartilage, the top part of the esophagus is manually compressed shut which theoretically would prevent reflux from regurgitating up into the throat.

It is based on this theory that anesthesiologists often perform cricoid pressure to prevent aspiration during intubation for surgery, especially if a patient is suspected of drinking/eating something prior to surgery.

The problem with cricoid pressure is that in order for this to work, it needs to happen continuously which may make it unrealistic and impractical for patients who suffer from LPR. Continuously means 24/7/365. Not just when symptoms are present (because it's too late than).

Reference:
Prevention of esophagopharyngeal reflux by augmenting the upper esophageal sphincter pressure barrier. Laryngoscope. 2014 Apr 29. doi: 10.1002/lary.24735.

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Mouthwash May Increase Risk of Oral Cancer

Drinking alcoholic beverages is known to increase risk of oral cancer. It is now suspected that using mouthwash containing alcohol (i.e., original Listerine) may also increase risk for oral cancer.

When it comes to drinking alcoholic beverages like beer, individuals who consume 50 or more grams of alcohol per day (approximately 3.5 or more drinks per day) have at least a two to three times greater risk of developing oral cancer than nondrinkers. Moreover, the risk of cancer is substantially even higher among individuals who consume this amount of alcohol and also use tobacco.

What people may not realize is that some popular over-the-counter mouthwashes ALSO contain alcohol... quite a bit of it with some containing up to 27% of volume. Alcohol is added to provide flavor and "bite." For example, Listerine contains alcohol concentrations of 21.6% in the flavored product and 26.9% in the original gold Listerine Antiseptic.

Whether alcohol is introduced into the mouth via beer or mouthwash, carcinogenic risk is present.

According to one preliminary research, the risk of developing oral cancer from mouthwash containing alcohol is almost 5 times higher than those who do not. Subsequent small studies have not supported this cancer risk, but in 2014, research performed on 3,956 patients did find an independent increased risk of cancer if alcohol-containing mouthwash was used 3 or more times a day.

It is hypothesized that alcohol content in mouthwashes allows for carcinogens to penetrate into the mouth lining increasing cancer risk.

Given the possible increased risk of oral cancer, it may be worthwhile to avoid mouthwashes containing alcohol, especially given there are plenty of alcohol-free mouthwashes commercially sold.




References:
The role of alcohol in oral carcinogenesis with particular reference to alcohol-containing mouthwashes. Aust Dent J. 2008 Dec;53(4):302-5. doi: 10.1111/j.1834-7819.2008.00070.x.

Carcinogenicity of alcoholic beverages Exit Disclaimer. Lancet Oncology 2007;8(4):292-293.

Interaction between tobacco and alcohol use and the risk of head and neck cancer: pooled analysis in the International Head and Neck Cancer Epidemiology Consortium. Cancer Epidemiology, Biomarkers & Prevention 2009;18(2):541-550.

Oral health, dental care and mouthwash associated with upper aerodigestive tract cancer risk in Europe: The ARCAGE study. Oral Oncol. 2014 Mar 26. pii: S1368-8375(14)00065-7. doi: 10.1016/j.oraloncology.2014.03.001

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30% of Patients with Reflux will NOT Respond to Medications

Specifically, patients who are suffering with throat symptoms of reflux will often not respond to proton-pump inhibitor (PPI) medications. Such throat symptoms include throat-clearing, phlegmy throat, cough, hoarseness, and globus. Known as LPR (laryngopharyngeal reflux), a study was done measuring the pH at the throat level after 4+ weeks of twice daily PPI.

This retrospective study found that although 67.4% had symptom normalization, 32.6% of patients showed no subjective or objective treatment response. For all patients whose symptoms did not normalize, pH scores also did not normalize.  For individuals whose symptoms normalized but whose pH scores did not normalize, there was a significant decrease in upright pH score.

Based on these findings, one should NOT assume that lack of response to reflux medications indicative of reflux being an incorrect diagnosis. Further study with a pH or impedance monitoring should be performed in non-responders to help figure out what is going on.

Reference:
Effects of Proton Pump Inhibitor Therapy for Laryngopharyngeal Reflux on Posttreatment Symptoms and Hypopharyngeal pH. Otolaryngol Head Neck Surg. 2014 Mar 19. [Epub ahead of print]

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Lisa Marie Presley Throat Cancer Scare

Image from Wikipedia

The National Enquirer reported 1/20/14 that Lisa Marie Presley suffered a throat cancer scare when she was told by a medical expert that "the 45-year-old singer’s throat is so severely ravaged that ... the damage could lead to deadly esophageal cancer!" [link]

The National Enquirer, which is not know for stellar journalism, goes on to report that she has been pushing her voice hard in order to succeed as a singer like her more famous father Elvis.

In spite of what the story implies, although singing can lead to vocal cord damage (i.e., nodules)... singing in and of itself does not cause or lead to increased risk of cancer.

However, uncontrolled reflux which can cause throat and vocal cord damage CAN lead to throat cancer. In one report, reflux can increase the risk of throat cancer by 78% (this risk is separate from esophageal cancer).

Source:
WORLD EXCLUSIVE: LISA MARIE THROAT CANCER NIGHTMARE. National Enquirer 1/20/14.

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Beatboxing Protective of the Vocal Cords?

Beatboxing is a popular vocal percussion technique that incorporates use of the entire vocal tract. Recently, research by Dr. Steven Simms (who I had the pleasure of working with briefly when we were both at Yale University in the 1990s) suggested that beatboxing techniques may actually protect against vocal cord injury.

Unlike singing where most of the sustained energy is directed at the vocal cord level, beatboxing makes extensive use of the entire vocal tract, especially the muscles of the throat.

Although more research is needed, it is not inconceivable that beatboxing techniques may potentially be helpful to patients who have suffered from vocal cord injury. The question is what techniques specifically and how it can be incorporated into voice therapy sessions. Furthermore, such vocal techniques may be more "acceptable" to teenagers who may scoff at more traditional strategies.

Check out this fiberoptic laryngoscopy video of a beatboxing artist.

Reference:
Functional Endoscopic Analysis of Beatbox Performers. Journal of Voice. Published Online 12/23/13. PII: S0892-1997(13)00243-9 doi:10.1016/j.jvoice.2013.11.007

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At-Home Rapid Strep Testing

Rapid strep test kits can be purchased by anybody to be done at home which may save parents/patients a lot of money in doctor visits for those prone to strep infections. Indeed, should a rapid strep test be positive, than you know that a doctor's visit is definitely worthwhile. (A doctor visit may still be worthwhile since a sore throat may be due to something else like cancer, aphthous ulcer, sinus infection, reflux, etc).

Such home kits (which in fact are the same kits used in medical offices) can be purchased online through Amazon. The price is surprisingly affordable at around the cost of a single copay $30 to do 25 tests.

However, with the purchase of such DIY kits, there are some pitfalls patients should be aware of if they decide to proceed.

1) Perform the internal controls that come with the kit!!! The kit may be a dud and needs to be tested against itself to ensure accurate results whether negative or positive. If the controls do not work, throw the whole test kit out and buy another.
2) You must follow the directions precisely, otherwise the test results will be unreliable. In other words, if the directions call for 4 drops, than it MUST be 4 drops (not 3 drops or 5). If directions state to wait 4 minutes... you must wait exactly 4 minutes. This literally is like precision baking.
3) The test strips need to be kept in protected, sealed bag and used immediately after taking one out, otherwise the test results will be unreliable.
4) When swabbing the throat, you MUST get the cotton tip on the tonsil and/or back wall of the mouth which than must be rubbed around a couple times. Getting the tongue or cheek will increase the risk of a false negative. As such, it may be worthwhile to invest in some tongue blades to help push the tongue down in order to perform this test properly.

Should patients elect to start performing home strep tests, please be aware that physicians will be obligated to not only REPEAT the testing but also examine the patient to ensure antibiotics are appropriate. An actual throat culture may be performed as well which is the gold standard test.

1) Repeat testing is required because the patient may not have followed the instructions precisely. For example, the test strips must be read at 5 minutes (variable depending on the kit). If test results are read past 5 minutes, it may incorrectly show a positive result.
2) Some patients unfortunately fabricate test results just so they can get an antibiotic without an office visit.
3) Some patients unfortunately also fabricate test results in order to skip work or school for personal reasons not related to an actual medical condition.
4) There are situations that even though the strep test is positive, no treatment may be recommended. The patient may be a strep carrier for which treatment of any kind is not recommended.

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Life-Saving Emergency Trach Performed in Restaurant

On Sept 23, 2013, a physician performed a life-saving emergency tracheotomy in a restaurant on a patron who was choking on a piece of meat. [link]

While eating dinner at The Mark Restaurant in California, Dr. Royce Johnson, an infectious disease doctor affiliated with UCLA, performed this procedure on Pauline Larwood, a female supervisor and a community college trustee.

Dr. Johnson saved this woman's life using a pocket knife and the hollow cylinder of a pen after a Heimlich maneuver failed to work.

Interestingly, Dr. Thomas Frieden, director of the CDC, who was also present in the restaurant assisted in the care by monitoring Larwood’s pulse during the incident.

Also present in the restaurant witnessing the emergency procedure were:

• Francis Collins, MD (director of NIH)
• Farming and business moguls Lynda and Stewart Resnick
• Rep. Kevin McCarthy, R-Bakersfield
• Assemblywoman Shannon Grove, R-Bakersfield
• State senator Jean Fuller, R-Bakersfield

Although typically surgeons are the individuals trained to perform tracheotomies, bravo to Dr. Johnson who took the initiative in spite of the fact that he probably has never performed one.

I should also add that though media reports state that an emergency tracheostomy was performed, it is probably more likely that an emergency cricothyroidotomy was performed instead which is easier and less "bloody."

Source:
Dramatic dinner rescue involves knife, UCLA doctor and CDC chief. The Bakersfield Californian 9/24/13

CALIF. DOCTOR SAVES CHOKING DINER WITH KNIFE. The Associated Press 9/25/13

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What is the Best Antibiotic for Strep Throat?

The traditional answer for the best antibiotic to treat strep throat is penicillin. This antibiotic works astoundingly well... until it doesn't. Why is that?

Although in the lab, penicillin is probably the most effective antibiotic against Group A beta-hemolytic streptococci (GABHS) or "strep throat" infection, when it comes to human beings, it doesn't always work. A recent paper out of Georgetown elucidates the reasons why that might be the case and also explains why if you took a survey of ENT doctors, clindamycin and augmentin are perhaps the two most popular antibiotics used in our patient population (patients seen in an ENT practice suffering from recurrent and/or severe infections of the head and neck region).

Penicillin may fail to work because:

• presence of beta-lactamase producing bacteria that "protect" strep from penicillins
• absence of bacteria that interfere with the growth of strep
• co-aggregation between strep and Moraxella catarrhalis
• poor penetration of penicillin into the tonsillar tissue cells which allows intra-cellular strep and Staphylococcus aureus to survive

Indeed, in the treatment of recurrent and chronic strep throat, clindamycin or amoxicillin-clavulanic acid (augmentin) can eradicate both aerobic and anaerobic beta-lactamase producing bacteria as well as strep itself. Cephalosporins and clindamycin have superior intracellular penetration which enhances their efficacy as well.

Of course, if a patient has suffered from such severe and recurrent strep infections, it just might be time to remove and tonsils and adenoids surgically.

Reference:
Penicillin failure in the treatment of group A streptococcal pharyngo-tonsillitis: Causes and solutions. Journal of Pediatric Infectious Diseases. Volume 8, Number 2 / 2013 Pages 59-69

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Do Reflux Medications Increase Risk of Esophageal and Throat Cancer?

Image by Steven Fruitsmakk from Wikipedia

Over the last 30 years, the incidence of esophageal cancer has been steadily rising in spite of increased use of reflux medications. In fact, one can almost say that there is an inverse relationship between risk of esophageal cancer and reflux medication usage.

BUT, it is also a foregone conclusion that reflux increases the risk of esophageal and throat cancer too. So, why would there be an increased incidence of esophageal cancer when reflux is being better "controlled" now more than ever with medical acid suppression?

The answer might be bile... the substance made in the liver and secreted into the small intestine via the gallbladder. Bile is what helps the body digest dietary fat.

But when bile not uncommonly refluxes into the esophagus... bad things may happen, especially when acid production has been suppressed by reflux medications.

Disclaimer... The following is hypothetical and unproven.

Bile, if it happens to be in the esophagus or throat, is more destructive to the mucosal lining when acid is suppressed.

Bile salts/acids have fairly complicated acid-base properties, but an over-simplified explanation for the purpose of this blog is as follows.

Bile in a chemically unconjugated state has a pKa of 7. When such bile is in an acid environment (pH less than 6), it is insoluble and relatively harmless. However, when unconjugated bile enters a relatively alkaline environment (pH greater than 6), it becomes water soluble and "active" in its ability to damage mucosal linings.

As such, when acid suppression is induced by medications like zantac and prilosec, yes... the acid is suppressed but by the very fact that it raises the stomach and distal esophageal pH to a relative alkaline state, any bile that may be present now becomes activated and causes potentially just as much damage as acid.

And that's why over a prolonged period of time repeated bile exposure in a relative alkaline environment may explain why esophageal cancer incidence seems to be increasing as the use of acid reflux medications has increased.

Proof?

Regardless of the "how," does taking reflux medications actually increase risk of cancer???

In one study (2011), patients taking proton pump inhibitors were 61.3% to 81.5% more likely to develop esophageal pre-cancerous lesions or frank cancer (adenocarcinoma).

In another study published in the summer of 2013, it was found that patients with reflux were found to have a 78% increased risk of developing throat cancer. What researchers also found was that taking antacids for reflux (but NOT proton pump inhibitors or H2 blockers) seemed to protect against the development of throat cancer by 41% in patients with frequent heartburn.

To reiterate, antacids reduced risk of throat cancer... but NOT proton pump inhibitors like prilosec and H2 blockers like zantac.

Why? Because antacids work transiently to neutralize acid, but not suppress acid production whereas proton pump inhibitors and H2 blockers actually suppress acid production for a prolonged period of time.

The transient nature of acid neutralizers like TUMS allow for acid to still be produced thereby theoretically preventing bile from becoming soluble and damaging.

Prediction

So which is worse for you? Acid reflux or bile reflux? I'm not sure... but personally, I predict that once additional studies are performed that may ultimately strengthen the relationship between bile reflux and mucosal injury that may lead to cancer formation, reflux medications may go out-of-favor along with a class-action lawsuit. That's a big if... I might end up being completely wrong.

Of course, that may be the reason why drug companies specify that such reflux medications should not be used longer than 2 months and prescribing information stress "short-term" treatment rather than long-term.

More Confusion

We can also throw more mud into this messy predicament... Pepsin, which is a stomach enzyme that breaks down proteins, can also damage esophageal and laryngeal mucosa. However, it is most active in an acidic environment. Once pH levels rise above 6.5, pepsin becomes inactivated. At pH 8.0, it becomes irreversibly inactivated.

As such, acid and pepsin cause damage in an acidic environment. Taking reflux medications to eliminate the acid creates an alkaline environment.

However, an alkaline environment than activates bile which can also cause damage.

Treatment

So what to do?

Ideally, given this no-win situation, the best way to treat reflux would be to keep bile where it is supposed to be (in the small intestine) and acid/pepsin in the stomach where it is supposed to be.

As such, I suspect that even more emphasis will be placed on lifestyle/dietary changes for reflux control. Medication-wise, use of antacids and barrier-type medications like alginate will become the main way of treating reflux long-term while medications that suppress acid will be prescribed only for short-term treatment spans.

Surgical management of reflux will become much more accepted and popular for patients who suffer from bad reflux to try and restore proper anatomical compartmentalization of bile, acid, and pepsin. Surgical management will include LINX, TIF, Nissen, etc. (more info)

At the very least, certainly caution should be present when placing a patient on long-term acid suppression with medications like prilosec and zantac, especially when such medications are already known to cause a whole host of other problems including bone fractures, clostridium difficile infections,  and malabsorption of vitamins and minerals. (more info)

Special thanks to Dr. Kevin Gillian who assisted in writing this blog.


References:
Bile Acid. Wikipedia

Gastroesophageal reflux disease symptom severity, proton pump inhibitor use, and esophageal carcinogenesis. Arch Surg. 2011 Jul;146(7):851-8. doi: 10.1001/archsurg.2011.174.

Gastric Reflux Is an Independent Risk Factor for Laryngopharyngeal Carcinoma. Cancer Epidemiology Biomarkers & Prevention. Published Online First May 23, 2013; doi: 10.1158/1055-9965.EPI-13-0183

The otolaryngologic manifestations of gastroesophageal reflux disease (GERD): a clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury. Laryngoscope. 1991 Apr;101(4 Pt 2 Suppl 53):1-78.

Bile reflux gastritis and Barrett's oesophagus: further evidence of a role for duodenogastro-oesophageal reflux? Gut 2001 Sep;49(3):359-63.

Acid and bile reflux in erosive reflux disease, non-erosive reflux disease and Barrett's esophagus. Hepatogastroenterology. 55 (82-83), 442-7.

The role of bile acids in the neoplastic progression of Barrett's esophagus - a short representative overview. Z Gastroenterol. 50 (9), 1028-34.

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What are the Risks for Throat Cancer? (Humor)

Check out this info-advertisement photographed by Twitter user @durf showing the risks of throat cancer.

I truly think the American public is a bit smarter than this... though not perhaps in Ann Arbor, MI where this ad most likely got published (I suspect AATA is the Ann Arbor Transportation Authority). jk...

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Does Stridor HAVE to be Present for Diagnosis of Vocal Cord Dysfunction?

Laryngospasm, the most severe form of vocal cord dysfunction, does include stridor as a symptom. However, a patient can still suffer from vocal cord dysfunction and even laryngospasm without an obvious stridor present.

In order to understand stridor's relationship to vocal cord dysfunction (VCD), one must first understand what exactly is happening anatomically... or skip to the bottom of the article if you already understand the basics.

When a person breathes, the vocal cords move apart allowing air to pass easily through and into the windpipe. When a person talks, the vocal cords come together and vibrate allowing for voice production. [watch video]

Vocal cord dysfunction is when the vocal cords come together (instead of apart) when a person is trying to inhale air. Given the physically smaller airway created by the approximated vocal cords, the patient would typically experience shortness of breath and some wheezing.

Laryngospasm is when the vocal cords come completely together when a patient is trying to breath and stridor is typically produced with attempted strong inhalation against closed vocal cords.

Watch a video showing both types here.

As such, in order for stridor to be produced, TWO things must be present:

1) The vocal cords need to be nearly or completely closed together.
2) There must be strong breathing attempts

If any two elements are absent, stridor will not occur.

For example, if a patient is in a full-fledged laryngospasm attack, but is either breath-holding or making weak attempts at breathing, no stridor will occur.

Conversely, if a patient is suffering from a severe case of vocal cord dysfunction and is breathing hard enough, due to venturi effect against vocal cords that are almost closed (but still open), stridor like sounds may occur.

Venturi effect???

What's that?

In essence, it is a physics concept whereby there is a reduction in pressure when a fluid (or air) flows through a constricted section of a pipe (or airway) in this case.

In essence, the venturi effect as it applies to the voicebox, is a highly localized area of negative pressure created between the vocal cords when a person is breathing fast causing the vocal cords to come together even more... leading to more "sound" with breathing even if the vocal cords are not completely together.

It is perhaps one reason why athletes who suffer from vocal cord dysfunction may sound like they are suffering from laryngospasm during a VCD attack while exercising. Technically, it may not be laryngospasm because the vocal cords are still apart, but due to the venturi effect, causes a functional vocal cord closure leading to aggressive vocal cord vibration and a stridor-like sound production.

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Vocal Cord Tear Silences R&B Singer Frank Ocean

Image by Fred von Lohmann from Wikipedia

On July 25, 2013, R&B singer Frank Ocean was forced to cancel his entire Australian concert tour due to a small vocal cord tear.

After singing his opening night with a sore throat during which he reportedly sounded "noticeably off-key," he seeked medical attention and was informed of the unfortunate condition of his vocal cord. Listening to his voice on this YouTube video recorded during this fateful concert, his voice actually does not sound as bad as I would expect with a vocal cord tear. However, at time point 1:20, there was an obvious pitch break.

If a vocal cord tear was truly present, it must have been extremely small and not along the free edge because even with a small vocal cord tear located along the vibrating margin, the vocal quality would have been noticeably degraded throughout the vocal range. Why?


In order for the vocal cords to produce a clear voice, the vocal cords must come together and vibrate evenly. This vibration occurs on the vocal cord mucosa. ANYTHING that disrupts this mucosal vibration would result in a raspy voice including small bumps like a nodule or polyp, but also a vocal cord tear. Watch video of normal vocal cords in motion.

Small bumps typically cause problems in the voice only in the high range at quiet volumes because often the bump can vibrate along with the mucosa (just like a buoy on the ocean). As long as the vibration is unaffected, the voice comes out. As a bump gets bigger, a greater portion of the vocal range becomes affected.

A tear, however, depending on where it is located could affect the entire vocal range due to vibratory disruption as it moves to and around the tear (the tear acts like an anchored pillar in the ocean).

The only way to correct a tear is MANDATORY strict voice rest for several weeks. Further using the voice when injured like this may only "rip" the tear larger potentially causing a greater risk of scar formation and a permanent hoarse voice.

Strict voice rest means absolutely no talking and whispering. Such activities cause the vocal cords to come together and "bang" against the vocal cord tear preventing proper healing. I would even instruct patients to avoid even mouthing words as it causes the brain to "think" you are talking even if you are not. Essentially, the lips should always remain closed except when eating/drinking. The analogy would be if you have surgery done on the heel of your foot, you should not walk or put any weight on the heel, otherwise risk improper healing.

Here's an example picture of a vocal cord tear on both vocal cords in a patient suffering from viral laryngitis who did not quit using her voice for a prolonged period of time.

WHY would a vocal cord tear appear in the first place? Usually from excessively traumatic vocal abuse (ie, strong cough, scream, yell, etc).

Source:
Frank Ocean Suffers Tear to Vocal Cord, Scraps Australian Mini-Tour. Billboard Biz 7/26/13

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Vaccine to Prevent Throat Cancer

Spread through oral sex, it is well established that human papilloma virus (HPV) types 16 and 18 cause the vast majority of throat cancer especially in men... even more than smoking and drinking alcohol. What was not known, but suspected, was whether in BOTH men and women the HPV vaccine Cervarix (made by GSK) or Gardasil (made by Merck) would help prevent throat cancer as effectively as cervical cancer for which it is FDA approved for.

At least for the vaccine Cervarix, a randomized, control, double-blinded, prospective study has shown that it highly protects individuals from HPV 16 and 18 infection in the mouth/throat. The vaccine efficacy was calculated to be 93.3%. The big assumption being that reduced oral HPV 16/18 would lead to a decreased risk of throat cancer.

It is for these reasons that BOTH boys and girls are encouraged to get the HPV vaccine. We are talking about protecting our sons and daughters from getting throat and cervical CANCER later in life.

To be clear, more study is needed to really PROVE that such vaccines prevent throat cancer. For full disclosure, the weaknesses of this current study are as follows:

• It was performed only in women (the study would need to be replicated in males)
• The study lasted only 4 years... the question is whether life-long protection is present or will booster shots be needed?
• Does Gardasil also work for oral HPV 16/18?
• Does reduced HPV 16/18 presence in spit actually translate to decreased risk of throat cancer
• It is suspected that vaginal secretions carry a higher HPV viral load than the penis leading to a higher risk of throat cancer in men performing oral sex on infected women. As such, the other questions that need to be answered is whether such vaccines will:
     • Prevent a vaccinated woman from giving HPV to the man as well as
     • Prevent an infected woman to actually infect a vaccinated man?
     • Or, does BOTH partners need to be vaccinated to prevent HPV throat cancer?

It is truly an exciting time when vaccines can be given to prevent not only infections like mumps or shingles, but also cancer!

As a reminder, the HPV vaccines ONLY work when given to children before they become sexually active. It is too late to give the HPV vaccine for sexually active adults (ie, it won't work).

Source:
HPV Vaccine Found to Help With Cancers of Throat. NYT 7/18/13

Reference:
Reduced Prevalence of Oral Human Papillomavirus (HPV) 4 Years after Bivalent HPV Vaccination in a Randomized Clinical Trial in Costa Rica. PLOS One

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We Now Offer Rapid Saliva Test to Look for Laryngopharyngeal Reflux

When you compare a spit test to the current way of how throat level reflux (LPR) is determined via barium swallow, upper endoscopy (EGD), and 24 hour ph/impedance testing, it sounds quite attractive.

And we are one of the very few offices in the United States that offer this spit test. Even major laboratory companies like Labcorp and Quest do not offer this test yet.

How does such a test work?

It basically looks for a stomach protein called pepsin.

Given reflux is when stomach contents moves up towards the mouth and pepsin is a protein ONLY produced in the stomach... pepsin should NOT be found in the throat/mouth.

As such, the test can state yes or no whether LPR is present or not.

The steps to the test are as follows:

   

How good is the test?

Depending on the study, sensitivity ranges in the 80-100% (can actually detect reflux if truly present) and specificity is around 85% (truly no reflux if test is negative).

One test company is RDbiomed (in Europe) using their Peptest kit.

This test is currently not FDA approved yet and as such, is a test that is NOT covered by insurance at this time. Due to a special arrangement our office has with RDBiomed, the Peptest kit can be obtained in our office at a discounted price of $125 (compared to normal price of $175). Price includes the kit, test supplies, and courier shipping service.

Please note that this testing is ONLY offered to current patients of ours.

However, if you are not a current patient of ours, you can order this test yourself online as an individual without a visit to our office. It is recommended you take the standard 3 sample peptest. Click here for more information.

References:
Sensitive pepsin immunoassay for detection of laryngopharyngeal reflux. Laryngoscope. 2005 Aug;115(8):1473-8.

Rapid salivary pepsin test: Blinded assessment of test performance in gastroesophageal reflux disease. Laryngoscope. 2012 Jun;122(6):1312-6. doi: 10.1002/lary.23252. Epub 2012 Mar 23.

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PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus)

Only in kids, there is a VERY rare (and controversial) disorder where strep throat infections can rapidly lead to involuntary tics including chronic throat clearing, cough, head/neck movements, sneeze, etc as well as OCD behavior. Known as PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus), it is felt to be an autoimmune reaction triggered by antibodies produced by the body when fighting a strep infection. With this disorder, an evaluation with a pediatric neurologist is warranted.

However, what role if any an ENT may play is less certain. Obviously, the main ENT related concern is whether tonsillectomy and adenoidectomy is helpful.

Certainly, this surgery should be pursued if the child meets the guidelines of when T&A should be performed from an infectious standpoint in any child:

• 7 or more tonsil/strep infections within past 12 months OR
• 5 infections in each of the last 2 years OR
• 3 infections in each of the last 3 years

However, it has been demonstrated that T&A does NOT seem to affect the onset nor influence the neuropsychiatric course of a child suffering from PANDAS.

According to one research, no significant differences were found between children who had T&A and those who did not in terms of PANDAS classification, and OCD or tic severity. In fact, most children with PANDAS had surgery before onset of neuropsychiatric symptoms and surgery did not affect symptomology.

More info about PANDAS can be found here.

To find a doctor who is familiar with PANDAS, click here.

References:
Tonsillectomies and Adenoidectomies Do Not Prevent the Onset of Pediatric Autoimmune Neuropsychiatric Disorder Associated with Group A Streptococcus. Pediatr Infect Dis J. 2013 Mar 20. [Epub ahead of print]

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Does Drinking Alkaline Water Help With Reflux?

Image by WJ Pilsak from Wikipedia

Treatment in some reflux-sufferers may require addressing not just the acid in reflux, but also the pepsin. In one tantalizing research paper, alkaline water (pH 8.8) was found to instantly and permanently inactivate pepsin in vitro (ie, in a test tube). Pepsin is a stomach enzyme that can cause inflammation and mucosal damage when in the throat area. This peptic enzyme can be deposited outside the stomach due to laryngopharyngeal reflux (LPR) and can cause symptoms of globus, burning, hoarseness, chronic cough, chronic throat clearing, etc.

With pepsin triggered symptoms, treatment to resolve can become exceedingly frustrating given standard treatment with zantac, prilosec, and other "reflux" medications do not work as well. Furthermore, human pepsin remains stable at pH 7.4 and can be repetitively reactivated by acid from any source (ie, orange juice).

BUT... keep in mind that test tube results in this research may not necessarily translate to actual improvement in humans. However, drinking a small amount of alkaline water a few times a day (just enough to coat the throat) can't hurt.

Keep in mind that most tap and bottled waters (typically pH 6.7 to 7.4) would not be expected to affect pepsin stability.

I should also mention that drinking alkaline water will not do much to help acid reflux as the alkaline water will only briefly neutralize any acid and is ineffective for long-duration acid suppression. For those suffering from acid reflux, stick with the traditional reflux medications which work extremely well.

Reference:
Potential benefits of pH 8.8 alkaline drinking water as an adjunct in the treatment of reflux disease. Ann Otol Rhinol Laryngol. 2012 Jul;121(7):431-4.

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New Movie Trailer for Fauquier ENT YouTube

It has been an amazing experience with how successful our videos have been on YouTube. We now have 60+ different videos of ENT procedures that has been viewed over 247 million times since 2007. We also now have over 12,300 subscribers to our video channel.

To celebrate, a movie trailer of sorts has been created to introduce new viewers to the sort of videos they will see and will continue to see from us.

Check it out! And... if you haven't yet subscribed to our video channel, please do so!

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Former Bills QB Jim Kelly Diagnosed with Jaw Cancer

Image from Wikipedia

Former QB for the Buffalo Bills, Jim Kelly, announced that he has a squamous cell carcinoma of his upper jawbone.

He had been experiencing jaw pain since Dec 2012. When the pain failed to resolve with antibiotics, follow-up testing which probably included a CT scan revealed a cystic mass of the maxillary bone. Removal of this nickel-sized cyst in March 2013 revealed cancer.

Additional testing reported by Jim Kelly showed that the cancer has not spread elsewhere. Such testing may have included bloodwork and a PET/CT scan.

This Friday, a complete cancer resection operation will be performed. Given what information was provided, he will likely have his maxillary bone removed along with a rim of soft tissue until no pathological evidence for cancer is present. A limited neck dissection which entails removal of all the lymph nodes in the neck may also be performed.

Of course, after removal of his upper jawbone, there will be a big hole present. As such, he will likely also undergo simultaneous reconstruction to replace what was removed. Bone, muscle, and soft tissue will likely be obtained from either the leg or arm to reconstruct Mr. Kelly's jawbone.

It is also not unusual to have a feeding tube placed for some time to allow healing before oral intake is allowed.

This operation takes a LONG time... typically anywhere from 4-12+ hours depending on what is found during the operation.

Depending on final pathology which may take up to one week for results, Mr. Kelly may need to undergo further cancer treatment with radiation therapy with or without chemotherapy.

I wish him the best of luck!

Source:
Former Bills QB Kelly battling cancer of the jaw. Boston.com 6/3/13

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How Does Neuropathy Lead to Lump in Throat or Phlegmy Throat Sensation?

To preface, have you ever been to the dentist and received a novacaine injection prior to a dental procedure? Did you notice that where the injection is performed, it feels as if the area feels really swollen and also you feel like you are drooling... but than when you look in the mirror, there's no drooling and there's no swelling either?

In this dental situation where novacaine got injected leading to a temporary induced neuropathy...  a similar phenomenon can also occur in the throat region due to neuropathy most commonly triggered by a virus or throat-level reflux (LPR). This condition is called laryngeal sensory neuropathy (LSN).

And because the neuropathy occurs in the throat region... a sensation of swollen or lump feeling in the throat (globus) may occur just like the sensation in the face/jaw after getting numbed up for a dental procedure.

Similarly, a mucus phlegmy throat sensation may also occur just like a drooling sensation of the face/jaw after being injected with novacaine.

Such a swollen throat or phlegmy throat sensation can also be temporarily induced in normal patients when the throat gets numbed up with lidocaine or other anesthetic for a surgical procedure.

How is this condition treated?

First and foremost, other non-neurologic etiologies must first be ruled out with medications and extensive testing. Also, triggers that may have led to this neuropathy must be thoroughly addressed as well. Such testing may include allergy testing, specific food avoidance, 24 hour multichannel pH impedance, manometry, etc, etc.

SELSAP is a promising test to evaluate for laryngeal sensory neuropathy.

Once laryngeal sensory neuropathy is confirmed, medications like amitriptyline, neurontin, and tramadol can be tried.

For more information, click here for globus and here for phlegmy throat.

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